Information Collection

Model Notices

IC 195130 under ICR 201106-0938-022 · OMB 0938-1105.

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IC Title:

Model Notices

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.126 29 CFR 2590.715-2711 45 CFR 9815.2711

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,605,750	1,627,365	2,978,385
Annual IC Time Burden (Hours)	153,000	53,720	99,280
Annual IC Cost Burden (Dollars)	2,256,818	797,409	1,459,409

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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